CASE REPORT

DIARRHEA

Achmad syahid
111170002
Chief : dr. Irman Permana, Sp.A

FACULTY OF MEDICINE
SWADAYA GUNUNG JATI UNIVERSITY
CIREBON
2015

Pattients identity
Name

: Mr. AD

Age

: 2 years old

Sex

: male

Address

: Kaligawe

Date of admission

: 25/06/2015

Date of examination

: 27/06/2015

Mothers Patients

: Mrs. S

Age

: 23 years old

Address

: kaligawe

Occupation

: House Wife

Education Level

: Elementary School

History of taking
Chief complain : liquid bowel movements
History of present illness :
Patients come to the hospital emergency room with complaints
liquid bowel movements. One day before entering the hospital.
Vomiting > 3x daily. liquid defecation > 10 x / day, liquid
consistency, waste less, more water, slimy, yellow bloodless.
Complaints accompanied by vomiting 3x / day. Patients complain
of abdominal pain. Patients do not want to eat and drink. During
the patient's pain becomes more fussy and look weak but no loss
of consciousness. Cough, runny nose, and shortness of denying
patients.
Currently the patient drink formula coupled with rice side dishes
and fruit. According to the mother of the patient, the patient does
not have a food allergy.

Past medical history :

Patients have experienced diarrhea complaint
1,5 years old.
Family history of disease :

There is no family history of disease

Treatment of History

patients have given oralite from stalls but no effect on patient

 History of growth and development :

Gross motor : - learn to lift the head of the age of 2 months
- Crawling and sit without the other people of 5 months
- Learn to stand on its own without the assistance 13 months Soft motor : - reach
objects around the age of 4 months
- Trying to move goods ages 6 months
Talking : - laughing and screaming 3 months Social:
- smiled at the face of the age of 2 months
- Laughs when asked to play age of 3 months
Impression: age-appropriate growth and development

immunization history :
Hepatitis B
: 1x at after birth
BCG
: 1x. at 1 month
DPT
: 1x at 2 months
Polio
: 1x at 4 months
Measles
: 1x at 9 months

PHYSICAL EXAMINATION
General state

: looking illnes

General appearance

Height

: 12 kg

Weight

: 91 cm

Vital sign

Blood presure
Pulse
Respiration

: full alert

:-

: 110 x/minute, reguler, equal

: 24x/minute

Temperature : 36 C

flaring
Neck

: Conjunctiva anemic -/-, Sclera icteric -/-, Nasal

(-), POC (-)
: - Suprasternal Retraction (-)
- Lymphadenopathy (-)

Thorax

: - Symmetric with good expansion Intercostal

Head

retractions(-)
-

Lungs : Breath sounds vesicular right=left,

rales(-), wheezes(-), rhonchi(-)

- Heart : S1, S2, regular rhythm, no murmurs

 Abdomen : - Soft, non distended, non tender

- Epigastric retractions (-),

- Liver and spleen is non palpable
- increased bowel sounds (40 x/minute)

Extremities

: - Warm
- Acrocyanosis -/- Capillary refill time < 2

Neurological Examination
Meningeal reflex : Neck stiffness (-)

Brudzinsky I/II/III (-)

Cranial nerve
: pupil isochors 3 mm within normal
limit
Motoric
: within normal limit
Sensoric
: within normal limit
Patology reflex
: Babynsky +/+ ; Chaddock -/-,
oppenheim -/- ; Gordon -/-

Differential Diagnosis
Diarrhea acute mild-moderate without dehidration
Intolerance lactose

Further Examination
Hematology :
Hemoglobin

: 12 g / dl

Hematocrit

: 40 %

Leukocytes

: 13.000 / ul

Platelets

: 413,000 / ul

Stool :
Color: yellow
Blood: Smell: characteristic
Slime: Consistency: soft
Leukocytes: 1-3 / LPB
The eggs of worms: Erythrocytes: 0-1 / LPB

Working diagnosis
Diarrhea acute mild-moderate without dehidration

Treatment
IVFD KaEN 3 B 11 dpm
Sanmol syr 3 x 1 cth
Oralite ad libitum
Ranitidine 2 x 12,5 mg
Zinc 1 x 1 tab
Cotry syr 2 x cth

 Education
Parents are asked to bring the child back to the

hospital if symptoms of fever, bloody bowel

movements
Promotive and preventive

Breast milk is still given

personality of hygiene

washing hands before eating

Environmental Hygiene

Prognosis
Quo ad vitam

: dubia ad bonam

Quo ad functionam

: dubia ad bonam

Quo ad sanationam

: dubia ad bonam

Thank you